Among high-income nations, the United States has one of the highest rates of pregnancy-related death—and more than 80% of pregnancy-related deaths are considered to be preventable.
A recent Henry Ford Health study may have discovered one factor that’s contributing to this. Andrew Bossick, Ph.D., MPH, an assistant scientist at Henry Ford Health, led research to create an index of state legislation related to reproductive autonomy (or the ability to make decisions about and control contraceptive use, pregnancy and childbearing). He found states that have greater reproductive autonomy have lower rates of pregnancy-related death and preterm birth than states that have more restrictive policies.
“About one in ten births are preterm,” says Dr. Bossick. “In states with greater reproductive autonomy, we saw a reduction of about one per state. So about one tenth of those births would not be preterm when comparing the most autonomous states to the most restrictive states.
“There are also 17.3 pregnancy-related deaths per 100,000 live births. In the most autonomous states, we saw a reduction of six to eight pregnancy-related deaths per 100,000 compared to the most restrictive states. Even though these might look like small numbers, quite a large portion of those rates could be reduced if we had more states with a greater number of policies that support reproductive autonomy.”
Why is reproductive autonomy related to lower rates of pregnancy-related mortality & preterm birth?
There could be many factors at play, says Dr. Bossick. “For example, if you have less comprehensive sex education, you’re more likely to engage in risky sexual behavior and more likely to get pregnant at a young age, which we know is associated with these adverse outcomes.
“There are also many postpartum-related factors, for example immediate postpartum long-acting reversable contraception (LARC) before hospital discharge. This is a form of birth control that reduces short-interval pregnancy, or pregnancy less than 24 months after giving birth. Short-interval pregnancy is associated with preterm birth and other negative outcomes. Several factors have limited the use of postpartum LARC, including state Medicaid reimbursement policy.”
Mental health is another factor. “Autonomous states tend to have longer postpartum coverage for mental health—up to one year after delivery—compared to restrictive states,” says Dr. Bossick. “And depressive episodes and suicide are a leading cause of pregnancy-related death. So I think there’s a compounding effect of different mechanisms that are happening here.”
Maternal Morbidity & Reproductive Autonomy
Bossick’s research also found that restrictive states have lower rates of severe maternal morbidity (or unexpected outcomes of labor and delivery) but he says additional research may disprove this.
“If we had access to more robust data, we might have seen that more autonomous states are associated with lower rates of maternal morbidity,” Dr. Bossick says. “We used birth certificate data to record maternal morbidity, but there is a limitation to using birth certificate data to define maternal morbidity. Maternal morbidity includes 21 adverse indicators of labor and delivery. But birth certificates only capture five of those indicators: maternal transfusion, admission to the intensive care unit, vaginal tear, ruptured uterus, or unplanned hysterectomy. So we missed some other common indicators, like temporary tracheostomy or ventilation to assist breathing, the third leading cause of maternal morbidity.
“We also know that more restrictive states have less robust reporting of their data—it’s not as accurate—so that’s why we think we saw that autonomous states had higher rates of severe maternal morbidity when compared to restrictive states."
Reviewed by Andrew Bossick, Ph.D., MPH, an assistant scientist at Henry Ford Health.
